DELIRIUM IN THE ELDERLY CCSMH NATIONAL GUIDELINES-INFORMED INTERACTIVE CASE-BASED TUTORIAL

1
DELIRIUM IN THE ELDERLYCCSMH NATIONAL
GUIDELINES-INFORMEDINTERACTIVE CASE-BASED
TUTORIAL

• Teaching module prepared by
• Dr. M. Bosma, FRCPC

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INTRODUCTION

• Guidelines have been developed by the Canadian
  Coalition for Seniors Mental Health for the
  diagnosis and management of delirium in the
  elderly
• Please refer to the handout you have been given
  to work through the following case examples

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REFERRAL

• You are a seniors mental health clinician
  working in the hospital. You receive the
  following referral to see Mrs. Adele OLeary, who
  is a patient of the cardiovascular surgery
  service.
• Please see this 75 year old female who is POD6
  for CABGx3. She lays in bed most of the day and
  is not interacting with staff, which is impairing
  her recovery. She is confused, and appears sad
  and unmotivated. Please assess and treat for
  depression.

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WHAT IS YOUR DIFFERENTIAL DIAGNOSIS?

• Depression
• Delirium
• Dementia

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• Before you assess the patient, you wish to be as
  prepared as possible. You ask yourself the
  following question
• WHAT IS DELIRIUM?

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DSM-IV DEFINITION

• Core features of DSM-IV criteria
• Disturbance of consciousness with reduced ability
  to sustain, or shift attention
• Change in cognition or development of a
  perceptual disturbance not better explained by a
  preexisting condition
• Disturbance develops over a short period of time
  and tends to fluctuate during course of the day

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CLINICAL FEATURES

• Acute onset
• Usually develops over hours to days
• Onset may be abrupt
• Prodromal phase
• Initial symptoms can be mild/transient if onset
  is more gradual
• Fatigue/daytime somnolence
• Decreased concentration
• Irritability
• Restlessness/anxiety
• Mild cognitive impairment

Cole 2004 See CCSMH Delirium Guidelines p 22
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CLINICAL FEATURES

• Fluctuation
• Unpredictable
• Over course of interview
• Over course of 1 or more days
• Intermittent
• Often worse at night
• Periods of lucidity
• May function at normal level
• Psychomotor disturbance
• Restless/agitated
• Lethargic/inactive

Cole 2004 See CCSMH Delirium Guidelines p 22
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CLINICAL FEATURES

• Disturbance of consciousness
• Hyperalert (overly sensitive to stimuli)
• Alert (normal)
• Lethargic (drowsy, but easily aroused)
• Comatose (unrousable)
• Inattention
• Reduced ability to focus/sustain/shift attention
• Easily distractible
• External stimuli interfere with cognition
• May account for all other cognitive deficits

Cole 2004 See CCSMH Delirium Guidelines p 22
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CLINICAL FEATURES

• Disruption of sleep and wakefulness
• Fragmentation/disruption of sleep
• Vivid dreams and nightmares
• Difficulty distinguishing dreams from real
  perceptions
• Somnolent daytime experiences are dreamlike
• Emotional disturbance
• Fear
• Anxiety
• Depression

Cole 2004 See CCSMH Delirium Guidelines p 22
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CLINICAL FEATURES

• Disorders of thought
• Abnormalities in form and content of thinking are
  prominent
• Impaired organization and utilization of
  information
• Thinking may become bizarre or illogical
• Content may be impoverished or psychotic
• Delusions of persecution are common
• Judgment and insight may be poor

Cole 2004 See CCSMH Delirium Guidelines p 22
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CLINICAL FEATURES

• Disorders of language
• Slow and slurred speech
• Word-finding difficulties
• Difficulty with writing
• Disorders of memory and orientation
• Poor registration
• Impaired recent and remote memory
• Confabulation can occur
• Disorientation to time, place, and (sometimes)
  person

Cole 2004 See CCSMH Delirium Guidelines p 22
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CLINICAL FEATURES

• Perceptual disturbances
• Distortions
• Macropsia/micropsia
• Derealization/depersonalization
• Illusions
• Misinterpretation of external sensory stimuli
• Hallucinations
• May respond as if they are real
• Visual
• Often occur only at night
• Simple to complex
• Auditory
• Simple sounds, music, voices
• Tactile (less common)

Cole 2004
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DOES DELIRIUM PRESENT SIMILARLY IN ALL PATIENTS?

• NO
• THERE ARE THREE CLINICALLY RECOGNIZED VARIANTS

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CLINICAL VARIANTS

• 1. Hyperactive
• Restless/agitated - Aggressive/hyper-reactive
• Autonomic arousal - 15-47 of cases
• 2. Hypoactive
• Lethargic/drowsy
• Apathetic/inactive
• Quiet/confused
• Often escapes diagnosis
• Often mistaken for depression
• 19-71 of cases
• 3. Mixed
• 43-56 of cases

Cole 2004 See CCSMH Delirium Guidelines p 23
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• Now that you have familiarized yourself with the
  clinical presentation of delirium, you are ready
  to move on with the case.
• WHAT OTHER INFORMATION WOULD YOU LIKE TO KNOW
  ABOUT MRS. OLEARY?

17
PATIENT HISTORY

1. Past psychiatric history
2. Past medical history
3. Current medications
4. Family history
5. Personal history
6. Pre-morbid cognitive status

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CASE

• You now attempt to see Mrs. OLeary to obtain her
  history and observe her current mental status.
  She is dressed in a hospital gown lying in bed,
  looking older than her stated age. Her eyes are
  closed, and you have a difficult time rousing
  her.
• Her words are slurred and difficult to
  understand. She is unable to respond
  appropriately to your questions. She appears to
  be picking at things in the air. You are unable
  to assess her mood, but her affect is restricted.
  She is confused, and when asked where she is
  mumbles something about being in Newfoundland.

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DELIRIUM SCREENING TOOLS

• AS PART OF YOUR ASSESSMENT, WHAT ARE SOME
  POSSIBLE DELIRIUM SCREENING TOOLS YOU COULD USE?
• MMSE
• CONFUSION ASSESSMENT METHOD (CAM)
• MONTREAL COGNITIVE ASSESSMENT (MoCA)
• You attempt to perform an MMSE, but Mrs. OLeary
  is unable to pay attention long enough to
  complete the test

See CCSMH Delirium Guidelines p 29
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• As you are unable to obtain much information from
  Mrs. OLeary, what should you do now?
• OBTAIN COLLATERAL

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CASE

• You review the medical chart and speak with Mrs.
  OLearys daughter to obtain collateral
  information. You find out the following
  information.

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COLLATERAL

• No prior psychiatric problems
• No history of depression
• Past medical history
• Angina
• Hypertension
• Dyslipidemia
• Hearing impairment
• Uses hearing aid
• Hysterectomy (1985)
• Smoker (30 pack years)

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COLLATERAL

• Medications
• Metoprolol 25 mg BID
• Atorvastatin 20 mg OD
• ECASA 81 mg OD
• Multivitamin i tab OD
• Amitriptyline 10 mg HS
• Ramipril 5 mg OD
• Ranitidine 150 mg OD
• Hydromorphone 2-4 mg q2h prn
• Receiving approx. 6 mg/day

New medications
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COLLATERAL

• No family history of mental illness
• Personal history
• Mrs. OLeary is the second oldest in a sibship of
  six. She was born in Nova Scotia and achieved a
  grade 8 education. She worked in a store until
  she married at the age of 21. She then stayed
  home to raise 3 daughters. Her husband retired
  at age 65 and they spent much time in Florida.
  He passed away two years ago, and Mrs. OLeary
  now lives alone in a seniors apartment. Prior to
  surgery, she had a busy social life, and enjoyed
  knitting and playing weekly bingo. She does not
  drink alcohol.

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COLLATERAL

• Pre-morbid cognitive functioning
• Mrs. OLeary has occasionally been forgetting
  names of friends/family over the past year, but
  there are no other memory deficits.
• She is independent for all IADLs/ADLs
• She scored 30/30 on a recent MMSE done at her
  GPs office
• Her family now find her drowsy and confused,
  which gets worse later in the day

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DIAGNOSIS

• Now that you have collateral information, you
  summarize the case
• 76 year old female post-CABG
• Decreased level of consciousness
• Confused and disoriented
• Amotivated and apathetic
• Fluctuation of symptoms
• No prior history of depression
• No prior history of dementia

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• OF YOUR DIFFERENTIAL, WHICH IS THE MOST LIKELY
  DIAGNOSIS?
• DEPRESSION
• DELIRIUM
• DEMENTIA

DELIRIUM
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• WHAT TYPE OF DELIRIUM DO YOU THINK IT IS?
• HYPERACTIVE
• HYPOACTIVE
• MIXED

HYPOACTIVE
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• NOW THAT YOU HIGHLY SUSPECT A DIAGNOSIS OF
  HYPOACTIVE DELIRIUM, WHAT SHOULD YOUR NEXT STEP
  BE?
• DELIRIUM WORK UP
• You are looking for an underlying medical cause

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DELIRIUM WORK UP

• WHAT INVESTIGATIONS WOULD YOU CONSIDER ORDERING?
• CBC
• Electroytes
• BUN/creatinine
• Magnesium and phosphate
• Calcium and albumin
• Liver function tests
• TSH
• Urinalysis
• Blood gases
• Blood culture
• Chest x-ray
• ECG

See CCSMH Delirium Guidelines p 33
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DELIRIUM WORK UP

• REMEMBER THAT DELIRIUM IS A MEDICAL EMERGENCY!!
• IT IS IMPORTANT TO DO A PHYSICAL EXAMINATION THAT
  INCLUDES
• Neurological examination
• Hydration and nutritional status
• Evidence of sepsis
• Evidence of alcohol abuse and/or withdrawal

See CCSMH Delirium Guidelines p 33
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INVESTIGATION RESULTS

• You perform an appropriate work-up and order
  investigations. You obtain the following
  ABNORMAL results
• Na 147
• BUN 17.2
• All other results are normal
• WHAT DO THE ABOVE RESULTS SUGGEST?
• DEHYDRATION

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• Now that you have made a diagnosis of delirium
  and performed the appropriate work-up, you need
  to make a treatment plan. Before you can do
  this, you need to learn more about the
  epidemiology and etiology (cause) of delirium.
• IS DELIRIUM A COMMON DISORDER?
• YES
• It occurs in up to 50 of older persons admitted
  to acute care settings

See CCSMH Delirium Guidelines p 23
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EPIDEMIOLOGY

• Minimal info on community incidence
• Age gt85 10 3 year incidence
• Age gt65 with dementia 13 3 year incidence
• Most studies focus on in-patients
• Admission to medical unit
• 10-20 prevalence at time of admission
• 5-10 incidence during hospitalization
• Special populations
• Long-term care home residents 6-14
• General surgical patients 10-15
• Cardiac surgery patients 30
• Hip fractures 50
• Age gt65 admitted to ICU 70
• Palliative advanced cancer patients 88

Cole 2004 See CCSMH Delirium Guidelines pp 23-4
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EPIDEMIOLOGY

• Delirium is OFTEN UNRECOGNIZED!!
• Many cases undiagnosed
• 40 of elderly with delirium sent home from ED
  in one study
• Misdiagnosed as depression
• 40 of cases in one study
• Hustey et al 2002
• Cole 2004

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WHAT ARE RISK FACTORS FOR DELIRIUM IN THE ELDERLY?
Advanced age

• Advanced age
• Male sex
• Cognitive impairment
• Dementia
• Functional impairment
• Depression
• Sensory impairment
• Medication use
• Narcotics
• Psychotropics
• Alcohol abuse

• Severe medical illness
• Fever
• Hypotension
• Electrolyte abnormalities
• High urea/creatinine ratios
• Dehydration
• Hypoxia
• Fracture on admission
• Surgery
• Especially unplanned

Electrolyte abnormalities
High urea/creatinine ratios
Sensory impairment
Medication use
Surgery
WHICH RISK FACTORS DOES MRS. OLEARY HAVE?
See CCSMH Delirium Guidelines pp 24-26 ( Table
2.1)
37
WHAT ARE COMMON POTENTIAL CAUSES OF DELIRIUM?

• Drug-induced
• Sedative/hypnotics
• Anticholinergics
• Opioids
• Alcohol and drug withdrawal
• Surgical procedures
• Infection
• Pneumonia
• Urinary tract infection
• Fluid-electrolyte disturbance
• Dehydration
• Severe pain

• Metabolic endocrine
• Uremia
• Hypo/hyperthyroidism
• Cardiopulmonary hypoperfusion and hypoxia
• CHF
• Intracranial
• Stroke
• Head injury
• Sensory/environmental
• Sensory impairment
• Acute care settings

Drug-induced
Surgical procedures
Sensory/environmental
Fluid-electrolyte disturbance
WHAT ARE POTENTIAL CAUSES IN MRS. OLEARY?
See CCSMH Delirium Guidelines pp 24-26 ( Table
2.1)
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ETIOLOGY MNEMONIC

• Infectious
• Withdrawal
• Acute metabolic
• Trauma
• Central nervous system pathology
• Hypoxia
• Deficiencies (nutritional)
• Endocrinopathies
• Acute vascular
• Toxins/drugs
• Heavy metals

See CCSMH Delirium Guidelines p 31 (Table 3.1)
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HIGH RISK MEDICATIONS

• Sedative/hypnotics
• Benzodiazepines
• Barbituates
• Antihistamines
• Anticholinergic drugs
• Oxybutynin
• Trycyclic antidepressants
• Antipsychotics
• Warfarin
• Furosemide (Lasix)
• Cumulative effect of multiple drugs

• Narcotics/opioids
• Histamine blocking agents
• Ranitidine
• Anticonvulsants
• Phenytoin
• Antiparkinsonian medications
• Dopamine agonists
• Levodopa-carbidopa
• Benztropine

See CCSMH Delirium Guidelines p 39 (Table 4.1)
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MRS. OLEARYS MEDICATIONS

• Metoprolol 25 mg BID
• Atorvastatin 20 mg OD
• ECASA 81 mg OD
• Multivitamin i tab OD
• Amitriptyline 10 mg HS
• Ramipril 5 mg OD
• Ranitidine 150 mg OD
• Hydromorphone 2-4 mg q2h prn
• Receiving approx. 6 mg/day

Amitriptyline
Ranitidine
Hydromorphone
WHICH MEDICATIONS MAY CAUSE DELIRIUM?
41
CASE

• YOU HAVE NOW IDENTIFIED SEVERAL RISK FACTORS AND
  POTENTIAL CAUSES FOR THIS CASE OF DELIRIUM.
  WHICH ONE IS THE MOST LIKELY CAUSE?
• YOU CANNOT SAY - MRS. OLEARY HAS SEVERAL
  DIFFERENT POTENTIAL CAUSES
• DELIRIUM OFTEN HAS A MULTIFACTORIAL ETIOLOGY
• REMEMBER
• NOT FINDING A SPECIFIC CAUSE DOES NOT INDICATE
  THAT A DELIRIUM IS NOT PRESENT - MANY CASES HAVE
  NO DEFINITE FOUND CAUSE

p 30 CCSMH Guidelines
42
MANAGEMENT

• YOU HAVE NOW MADE A DIAGNOSIS OF HYPOACTIVE
  DELIRIUM, AND IDENTIFIED SEVERAL POTENTIAL
  CAUSES. WHAT SHOULD BE YOUR FIRST MANAGEMENT
  STRATEGY?
• TREAT ALL POTENTIALLY CORRECTABLE CONTRIBUTING
  CAUSES OF DELIRIUM

43
MANAGEMENT

• WHAT ARE YOUR TWO BASIC APPROACHES TO MANAGEMENT?
• NON-PHARMACOLOGICAL
• PHARMACOLOGICAL

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NON-PHARMACOLOGICAL MANAGEMENT

• Assess safety
• Prevent harm to self or others
• Try to avoid physical restraints
• Establish physiological stability
• Adequate oxygenation
• Restore electrolyte balance
• Restore hydration
• Address modifiable risk factors
• Correct sensory deficits
• Manage pain
• Support normal sleep pattern

See CCSMH Delirium Guidelines pp 33, 35, 36
(Table 3.3)
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NON-PHARMACOLOGICAL MANAGEMENT

• Optimize communication
• Continuous monitoring of mental status
• Calm, supportive approach
• Avoid confrontation
• Use re-orientation strategies
• Clock, calendars
• Provide staff consistency
• Involve friends/family
• Promote meaningful activities
• Provide education about delirium
• See CCSMH Guidelines pp 33, 35, 36 (Table 3.3)

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NON-PHARMACOLOGICAL MANAGEMENT

• Mobilize the older person
• Support routines
• Encourage self care
• Optimize environment
• Avoid sensory deprivation and overload
• Minimize noise to promote normal sleep pattern
• Provide appropriate lighting
• Reduces misinterpretations
• Promotes sleep at night
• Provide familiar objects
• Evaluate response to management
• Modify as needed

See CCSMH Delirium Guidelines pp 33, 35, 36
(Table 3.3)
47
PHARMACOLOGICAL MANAGEMENT

• General principles
• Psychotropic medications should be reserved for
  patients in distress due to agitation or
  psychotic symptoms
• In the absence of psychotic symptoms causing
  stress, treatment of hypoactive delirium with
  psychotropic medications is not recommended
• Psychotropic medications are not indicated for
  wandering
• Aim for monotherapy at the lowest dose
• Taper as soon as possible

See CCSMH Delirium Guidelines p 41
48
PHARMACOLOGICAL MANAGEMENT

• WHAT TYPES OF MEDICATIONS ARE FREQUENTLY USED IN
  MANAGING THE SYMPTOMS OF DELIRIUM?
• ANTIPSYCHOTICS
• (TYPICAL, ATYPICAL)
• BENZODIAZEPINES
• CHOLINESTERASE INHIBITORS
• OTHERS

See CCSMH Delirium Guidelines pp 41-44
49
TYPICAL ANTIPSYCHOTICS

• RCT evidence for haloperidol
• Preferred over low-potency antipsychotics
• Less anticholinergic
• Less sedating
• Range of doses/formulations available
• WHAT DOSE WOULD YOU CONSIDER?
• START LOW
• For example 0.25-0.5 mg od-bid

See CCSMH Delirium Guidelines pp 41-44
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HALOPERIDOL

• WHAT SIDE EFFECTS WOULD YOU MONITOR FOR?
• QT prolongation
• Risk of ventricular arrhythmias
• Consider getting a baseline ECG
• Extrapyramidal side effects
• Acute dystonia
• Parkinsonism
• Akathisia
• Neuroleptic malignant syndrome
• Orthostatic hypotension (falls)
• Oversedation

See CCSMH Delirium Guidelines p 42
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ATYPICAL ANTIPSYCHOTICS

• Some evidence for risperidone, olanzapine, and
  quetiapine
• Clozapine is NOT recommended
• Lower rates of extrapyramidal side effects
  compared to haloperidol
• Considerations
• Olanzapine has anticholinergic properties
• Metabolic syndromes
• Glucose dysregulation
• Hypercholesterolemia
• Less relevant if used for short duration
• Increased risk of stroke/mortality in dementia
  patients
• Possibly less relevant if used for short duration

See CCSMH Delirium Guidelines pp 42-43
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ATYPICAL ANTIPSYCHOTICS

• Dosing
• Risperidone
• 0.25 mg od-bid
• Olanzapine
• 1.25-2.5 mg/day
• Quetiapine
• 12.5-50 mg/day
• Preferred if patient has
• Parkinsons Disease
• Lewy Body Dementia

See CCSMH Delirium Guidelines p 43
53
OTHER TREATMENTS

• Benzodiazepines
• Indicated for treatment of alchohol or
  benzodiazepine withdrawal
• As benzodiazepines can exacerbate delirium,
  their use in other forms of delirium should be
  avoided
• Cholinesterase inhibitors
• Some evidence in case reports
• Other agents (eg trazodone) have limited evidence
  base

See CCSMH Delirium Guidelines p 44
54
CASE

• YOU SUGGEST THE FOLLOWING RECOMMENDATIONS TO THE
  SURGERY TEAM
• Correct hypernatremia
• Correct dehydration
• Give Mrs. OLeary her hearing aid
• Create a calm, supportive environment
• Frequently re-orient patient
• IN SPITE OF THESE MEASURES, MRS. OLEARY
  CONTINUES TO PRESENT WITH SYMPTOMS OF HYPOACTIVE
  DELIRIUM

55

• WOULD YOU TREAT MRS. OLEARY WITH AN
  ANTIPSYCHOTIC MEDICATION AT THIS POINT?
• NO
• She is not agitated
• She is not distressed by symptoms of psychosis

56
MEDICATION REVIEW

• YOU DECIDE TO REVIEW MEDICATIONS - COULD YOU MAKE
  ANY HELPFUL CHANGES?
• Metoprolol 25 mg BID
• Atorvastatin 20 mg OD
• ECASA 81 mg OD
• Multivitamin i tab OD
• Amitriptyline 10 mg HS
• Ramipril 5 mg OD
• Ranitidine 150 mg OD
• Hydromorphone 2-4 mg q2h prn
• Receiving approx. 6 mg/day

--------------------------------------
--------------------------------------
--------------------------------------------------
---
CONSIDER USING ACETAMINOPHEN INSTEAD OF OPIOIDS
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CASE

• Your medication suggestions were followed, and
  Mrs. OLearys pain is adequately treated with
  acetaminophen. Over the next few days, her
  mental status dramatically improves and she is no
  longer confused and drowsy. It seems as though
  the delirium has been cured.
• WHAT IS THE LONG TERM OUTCOME OF DELIRIUM?

58
DELIRIUM OUTCOME

• Poor prognosis in the elderly
• Independently associated with
• Increased functional disability
• Increased length of hospital stay
• Greater likelihood of admission to long-term care
  institution
• Increased mortality
• 1 month 16
• 6 months 26
• Symptoms often persist 6 months later

Cole 2004
59
CASE

• Approximately three years later, Mrs. OLeary is
  admitted to orthopedic surgery with a fractured
  hip from a fall. After a surgical repair, you
  are asked to see her on POD6.
• She is somewhat lucid in the mornings, but
  becomes very agitated in the afternoons. This
  lasts most of the night, during which time she
  often yells and tries to get out of bed. She
  also hit a nurse while receiving care.

60
CASE

• You take the same approach as before, and find
  out that she was diagnosed with Alzheimers
  Disease two years ago. She now lives in an
  assisted living facility.
• You perform an appropriate medical work-up, and
  all investigations are within normal limits. Her
  medications are the same, except she is getting
  morphine for pain every four hours. You are
  unable to perform an MMSE as she is very agitated
  and obviously confused.

61

• WHAT IS THE MOST LIKELY DIAGNOSIS?
• DELIRIUM
• HYPERACTIVE TYPE

62

• WHAT RISK FACTORS DOES MRS. OLEARY HAVE FOR
  DELIRIUM?
• Advanced age
• Dementia
• Medication use
• Opioids (morphine)
• Fracture on admission
• Hearing impairment
• Past history of delirium

63
CASE

• The treatment team optimizes the environment, and
  morphine is discontinued. However, Mrs. OLeary
  continues to be very agitated at night, and hit
  one of the nurses again.
• WHAT IS YOUR NEXT STEP?
• PHARMACOLOGICAL MANAGEMENT

64
CASE

• Using your previously acquired expertise on
  treatment of delirium, you suggest starting
  haloperidol in small twice daily doses. The
  treatment team asks Mrs. OLeary if she will
  accept treatment with this medication, but she
  does not seem to understand.
• WHAT MUST THE TREATMENT TEAM DO AT THIS POINT?
• ASSESS CAPACITY TO MAKE TREATMENT DECISIONS

65
CAPACITY

• To have capacity to make treatment decisions, one
  must be able to
• Communicate a decision
• Demonstrate an understanding of the information
  material to the decision
• Rationally be able to manipulate the information
  material to the decision
• Demonstrate an appreciation of the nature of the
  situation including reasonably foreseeing
  consequences of the decision options
• See CCSMH Delirium Guidelines p 47

66
CASE

• The treatment team finds Mrs. OLeary is not
  capable of making treatment decisions, and gets
  her daughter to be a substitute decision maker.
• Mrs. OLeary is treated with haloperidol 0.5 mg
  bid, and gradually returns to her baseline
  functioning with resolution of agitation.

67
CASE

• Shortly before discharge home, Mrs. OLeary
  acutely becomes confused and agitated at night
  again.
• WHAT WOULD BE YOUR NEXT STEP?
• MEDICAL INVESTIGATIONS
• (To rule out a medical cause)

68
CASE

• A new round of medical investigations is ordered,
  and urinalysis shows the presence of a urinary
  tract infection.
• Mrs. OLeary is treated with an antibiotic, and
  the delirium resolves. She moves back to the
  assisted living facility, and you await the next
  referral.

69

• QUESTIONS?

70
REFERENCES

• Cole, Martin B. Delirium in Elderly Patients.
  American Journal of Geriatric Psychiatry 121,
  January-February 2004.
• Hogan et al. National Guidelines for Seniors
  Mental Health The Assessment and Treatment of
  Delirium. Canadian Coalition For Seniors
  Mental Health. May 2006.
• Hustey et al. The Prevalence and Documentation
  of Impaired Mental Status in Elderly Emergency
  Department Patients. Ann Emerg Med 2002
  39248-253.